HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 623 OSGOOD STREET 4/19/2022 Commonwealth of Massachusetts AECEtvED
City/Town of APR 19 2022
b System Pumping Record THANDOVEB
Form 4 TOWN OF t4ovj TMEN
T
HEALTH
DEP has provided this form for use-by local Boards of Health. Other forms may beused, but the
information,must be substantlally the same as that provided here. Before using.this form,check with yo
local Board of Health to determine the form they use. The System Pumping Record must be submitted
the local Board of Health or other approving authority.
A. Facility Information
1. S s Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Lei
Right ide building, Left/Righ front of building, Left/Right rear of building, Under deck
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use only the tab
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use the return
key. 4111 own State Zip Code
2. Sy m Owner:
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Name
Bnm
Address(if different from location)
MA
City/Town State ip Code
&11�
Telephone Number
B. Pumping Record '2
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Component: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ElGrease Trap
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❑ Other (describe): --
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed condition of component pumped:
6. System Pumped By:
David Tiney Mass F5821
Name Vehicle License Number
Bateson Enterprises, Inc.
Company - -- -- --
7. Loc i here contents were disposed:
LS Lowell Waste Water
Signature of Hauler Date